Provider Demographics
NPI:1376016873
Name:BLACK, MICHAEL VINCENT (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VINCENT
Last Name:BLACK
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1023
Mailing Address - Country:US
Mailing Address - Phone:516-639-8669
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-606-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0022482255A2300X
NY023345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer